SutureBook PDF

Back to the SUTURE: Your Roadmap to Understanding & Mastering Suturing
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D
id you ever feel something was impossible to achieve?
I sure did (and many, many times over) and I’m not here to tell you
that everything is possible in life. It isn’t.
On the other hand, just as many things that feel insurmountable are achieved
once you commit and finally tackle them.
It’s not that things are impossible.
It’s your mind telling you, “It’s Impossible.”
Why?
Our brain is programed to be in pure survival mode. In that sense, the brain can
be our worst enemy. It will “tell us” certain things are impossible in order to
protect us from harm and to avoid risks and failures. Therefore, we often hesitate
to try new things, explore uncharted territories, and go on adventures that can
benefit our future. The brain is also where our fears live, which again are meant
to serve one purpose—to protect us from harm and give us a better chance to
survive.
In our current world, existential fear is rare. We live in safe and mostly prosperous
societies, but the primitive emotions like fear, hesitation, and self-doubt have
been there for millions of years before we were civilized.
Nowadays, pure survival is easy but not a good enough goal for you and me. We
all want to expand, grow, and prosper, and implementing surgery is one way to
do that. The sad reality is that many dentists live in “survival mode” with
hesitations and self-doubt because they were told they couldn’t do it. Some of
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these discouraging voices are external but more often internal, coming from the
primitive part of the brain. So you are led to believe things are hard and
impossible.
So let’s go back to word, “Impossible.”
Very few things truly are “impossible” in life. You see people do the “impossible”
every day—break records, accumulate wealth, reach mega-success, and even
sleep-train a baby in three days (I thought this was “impossible” until I actually
did that).
So here are the first tips of this book
and the keys to your success:
If you see at least one person achieve something you consider “impossible,” then
this is irrefutable proof that your assumption is wrong.
Rather than thinking something is impossible, you need to switch you mindset to,
“There is something I don’t know and this person does.”
The step after that is to figure out what person did to overcome the
“impossibility.”
Here’s another mind trick: From now on use invisible quotations with the word
“impossible” or any other self-defeating term. Very few things are. Dentists just
like you are doing it, and so can you.
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I hope you’re cool with these concepts because if not, it’ll be a bit more difficult
for you to move forward fast with suturing.
Now let’s take it a step further.
Would you be able to learn a critical surgical skill in 7 days?
Would you do it in 7 hours?
I’m not just talking about any skill.
I’m referring to the crucial skill you can’t do without and that every surgeon must
master.
I’m talking about the pinnacle of surgery. A skill you may be struggling with now
and desire to master to finally feel like a complete surgeon.
SUTURING: Your ability, with

your bare hands, to connect
living structures with a needle
and a thread and close a surgical
wound. It’s one of the most
important skills a surgeon must have. (And who doesn’t want to be and operate
like a top surgeon?)
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Mastering suturing may feel “impossible” for you today.
You love surgery and know how important it is for your success but feel insecure
about your suturing skills. The same principle applies here.
Countless dentists already mastered the suturing game.This is your irrefutable

proof that it’s not “impossible” because it was done by dentists just like you.
These dentists don’t have any extraordinary talent and haven’t even spent years
learning and practicing. They simply followed a well-paved path that led them to
where they are today.
Here’s my second and third advice in this book:
Don’t judge how far you can go based on where you are today, and
don’t let self-doubt stop you from achieving what you want.
Here’s my promise:
By reading this book, you are starting your first step in your roadmap to master
suturing.
It will change your mindset and make you ready to acquire some serious suturing
skills, eliminate previous dogma and misconceptions, and allow you to translate
the knowledge you gain into practical actions in your practice.
Even if:
• You don’t have much experience,

• Hate suturing, and . . .
• . . . are frustrated with your current skills (or lack of).
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This is what it will take from you:
Simply follow the instructions, my friend.
What do I mean by that?
I’ve taught thousands of dentists over the years,

and most did great with suturing. However, in
every group of doctors, some try to re-invent the
wheel, improvise, or go out of sequence with
regards to the steps.
I tell them the same, “Follow the instructions, my

friends.”
Once you get the hang of it, cool! Start modifying and trying out things.
Come up with your own way to do things, and who knows? You may be on to
something new and better (yes, you have the capability to improve upon what
you learn and invent your own; don’t let anyone discourage you).
But first—To master suturing, you must follow the instructions to acquire the
basics that are proven to work. This is your safety net to fall back on and to have
predictable success. Don’t invent your own techniques while you are training!
You must follow the instructions step-by-step. No deviations.
Do as I do initially to create effective and predictable knots and surgical wound

closure.
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Don’t deviate and don’t trust your intuition. This comes later. You don’t have
surgical intuition yet. It’ll come later.
This approach sounds a bit military but that’s what works. When you’re in basic
training, you follow the leader and follow the instructions. This way, it’ll a bit
difficult for you in training but “easier in battle” during surgery.
WHAT’S HOLDING YOU BACK?
First, you need to be stripped from the common

misconceptions and dogma that are holding you
back.
This is the first step in turning you into a suturing

master.
Second, I show you what works in my hands in most cases. I give you the tools to
do it on your own and the resources to practice and gain clarity and confidence.
Here’s my plan for you to grow your suturing skills:
I put everything you need to know in front of you and what to do with all that. On
your end, follow the instructions. Simple.
Can we shake hands on that?
Now that we have a basic agreement, let’s get rid of some things you were
“hypnotized” to believe in.
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Suturing is not what you were indoctrinated to believe it is.
It’s not a secret skill reserved to specialists or to uber-talented dentists.
It doesn’t take decades of practice or using instruments and materials available to

only a few.
It is not as complex as you may think it is and doesn’t require talent or even
previous experience.
The Three Pillars of Suturing
Suturing is only about 3 things that, once you are exposed to, will unleash the
hidden power of suturing mastery within you.
Here’s SECRET #1:
Of all the suturing techniques I use, 95%

are simple. Specifically, simple interrupted
technique.
Yes. Just one entry and one exit point and

tying one knot. Basic stuff.
So obviously, the technique is not the most important factor in mastering the
suturing process.
The “secret sauce” is understanding and implementing safety principles, choosing

the right materials, and applying the right mechanics—all of which are beyond
technical skill.
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If you’re like most dentists, suturing is a struggle.
Tears, entanglement, knots opening, flap cut-outs, sutures that

“poke” the patient, and more
unpleasant suture problems and complications.
You may even shy away from surgery altogether because you lack confidence in
suturing.
Well, confidence can be acquired. Clarity can be created.
In this book, I’m going to start our suturing teaching and coaching journey.
Here’s what NOT to do:
• Don’t give up or be discouraged by anyone.

• Don’t underestimate what you can achieve with the right tools, guidance,
and a shift in your mindset.
• Don’t feel bad if you never took the time to properly learn suturing and
didn’t maximize your potential.
We always operate at 100% potential based on the mindset we have at the time.
Our mindset is technically our ceiling. This is how we grow: We change our
mindset.
I know you can master this suturing

thing.
No matter if you are just starting out or if you
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have been practicing for 10, 20, or 30 years. You probably noticed there are not
too many resources to learn from.
Suturing Dead-End
It feels like there is nowhere to turn to if you desire to learn suturing.
I couldn’t find good resources for my own education. I looked everywhere, online
and offline, and had to go through years of challenges.
There are only a few outdated books and courses, which was a surprising fact to
me.
There could be only three explanations:
(1) Your surgery teachers take it for granted that you already know how to
suture and don’t focus on that. They teach you the steps of the surgery but
glance over suturing.
(2) Your teachers know how to suture but don’t know how to teach it.
(3) The suturing knowledge is being hoarded. It is not shared intentionally
because everybody knows it’s the “secret sauce” for successful surgeries.
No transparency in education. Wow.
IT’S TIME for more transparency in surgical training.
In this book, I open the curtains and reveal the most effective suturing secrets
the world’s top surgeons are using.
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Howard Farran, founder of DentalTown, told me the following during an

interview:
“You suture at the FREAK level. You’re like Picasso when you saw.”
Howard meant to give me a compliment but he was wrong (he looked kind of
shocked when I showed him the zPAD).
I don’t have any special talents or magical skills and I use simple suturing
techniques. I’ve done a lot of suturing for the past 20 years and have clarity.
Suturing is all based on the three principles we’ll explore together in the teaching
system I developed four years ago. It makes suturing simple and shows you how
to suture like a periodontist.
I created this system when I got frustrated with the fact that dentists are
intimidated by suturing. I was looking for a solution to create a transformation in
surgical training, and FAST.
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There was no time to waste.
In this system, I want every dentist to
• go back to sound surgical principles,

• go back to optimizing safety, with clarity and confidence
in suturing.
Therefore, I called this book BACK TO THE

SUTURE.
It’s a tribute to the 1980s movie with a similar name. Sometimes we need to go
back to basics, fix some things there so we can have a better future. That was the
essence of the movie and the essence of this book. I will take you back into the
core elements of suturing so you can grow from there in a simple and predictable
way (simple beats complex any day, as far as I’m concerned).
The new suturing system has been tested live on real dentists and works like
magic. Dentists who went through this training keep telling me the following (or a
variation of it):
“I finally GET suturing!”

It even worked on a non-dentist (a “normal” person) who was disabled in one
hand at the time of training. Even so, some of his suturing results were better
than the trained dentists’ results.
If this works on a person with no dental knowledge
and with a physical disability, Do you think it’ll work for you?
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Let’s get right to it because I value your time and we’ve got some work to do
together.
Thank you for the gift of your time to read this. The roadmap to suturing success
starts here.
Everyone operates at 100% capacity of their current mindset ceiling.
So how would you increase your potential if you’re already at 100%?
By changing mindsets.
This way, you can reach higher and higher

levels of success. The concept means you
are doing well now, within your current
knowledge and state of mind.
You must keep changing and transforming to get to where you want to be (this
applies for almost anything in life).
So let’s change some mindsets.

This is your first mindset shift about suturing:
Suturing begins before you make the first incision
Naturally, it’s important to design your incisions and flap to achieve the surgical
goal you have planned.
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Here is the twist.
As I plan my flap and incisions, I consciously think, “How am I going to close this
up?”
This mindset keeps me conservative and allows me to create a better flap design
that naturally enhances healing. It also keeps me calm during the procedure
because I know I’ll have good closure at the end.
One of my surgical success secrets is that I’m able to visualize a procedure from
start to finish—and that includes suturing. I want that ability for you, as well.
Don’t let your fear of suturing dictate the surgery. I’ve seen so many dentists
place implants in a flapless approach simply because they lack clarity about
suturing.
This first mindset shift is going to change things for you.
Consciously thinking about the suturing before making your first incision will make
your mind think bigger, eliminate fear, make smarter decisions, and create
openness for growth.
Here’s the next step in growing your suturing skills:
Be your own true critic.
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Immediately post-op 1 week post-op
Take a photo at the end of the procedure (showing the flap) and then a photo at
the 1-week post-operative visit (most dentists don’t take follow-up photos).
Place the photos side by side and compare with 100% honesty. You must also take
100% ownership for the results. I don’t mean to say that you have control over
the patient’s individual healing. You can’t control that, but you are 100%
responsible. You own the case, and that is true for success and failure.
When you compare the immediate post-op photo with the 1-week post-op,
something magical happens.
The learning and growth are just in front of your eyes.
Compare the knots and the short suture ends: How different do they look a week
later?
Are they still there? Are they loose or open?
How do the flap positions compare? Are the incisions open?
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Are the flaps loose? Do you see sloughing?
How does the color of the tissue compare? What is the status of inflammation?
By doing this for every surgery, you will start detecting your true
points of strength and weakness.
Don’t worry. You will not have to do this forever.
What I’m trying to teach here is to be honest and realistic with yourself and
develop unbiased judgement.
It also teaches you accountability and ownership. We are always responsible for
the outcome, good or bad. That is how a top surgeon operates.
The principle of unbiased self-analysis is critical!
You can’t improve without bringing the pain points into your conscious mind.
Once you know you own shortcomings, we have a chance to find a solution.
This process will also allow you to communicate with me in an efficient way. This
way, you’ll be very specific about the things you need help with, and we are going
to save you a lot of time.
You see, when an athlete trains for the Olympics, their coach gets rids of
problems and bad practices first. A good coach changes your mindset (remember,
your potential is bound by your mindset ceiling). He or she will help you get rid of
the self-doubt and internal limitations that are holding you back. You need to
perfect what you’re good at, and that’s again the job of a good coach—to
enhance your strengths.
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I want you to be an Olympics-level surgeon.
My goal is to not just to teach you techniques and strategies like everybody else.
I can teach you all you need to know, but if you are holding onto a misconception
or have self-doubt, you will not learn and excel. Although you may feel you need
and want to learn, the dogmas and misconceptions engraved in your mind will
make you resist my teaching and prevent you from implementing and improving.
So we have to get rid of those first.
Keep in mind, learning something new is supposed to feel

uncomfortable and awkward.
It’s the key to progress and growth.
So, when I show you how to hold the instruments, needles, and sutures and how
to create twists, wraps, locks, etc., it is supposed to feel unnatural at first.
If it feels natural and organic, you didn’t go anywhere. You’re the old self with the
old mindset.
Some dentists complain about certain suturing movements that “feel weird.”
My response: “CONGRATULATIONS, you’re on the right track!”
I physically held the hands of dentists and oral surgeons to demonstrate how to
do things. It made many of them cringe. But after a few practices, it became
second nature. What felt weird now feels natural.
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Remember, we will be practicing at the Olympics level.
We are going to win Wimbledon with an amazing serve. To be at that level, we

have to get you out of our comfort zone, change your mindset, and rid you of self-
limiting beliefs and myths.
Here’s the first myth to eliminate:
Myth #1
“Only surgical specialists can suture at the high level.”
Dr. Howard Farran, founder of DentalTown, believes there is some type of magic
in the ability to suture at a high level.
Let’s dispel this myth. There's no magic. I don’t have secrets or rare talent.
There are no special skills needed
nor do you need talent
or years in practice to master suturing.
Dentists can suture at a high level if they know the principles and the rules and
follow a well-paved roadmap (it’s my job to give you this roadmap).
If you graduated dental school, you have sufficient manual dexterity and hand-
eye coordination. That’s all the talent you need to reach suturing mastery.
The second myth to eliminate.
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Myth #2
“I need to know all the different suturing

techniques perfectly to be good.”
Here’s the reality:
You need two suturing techniques that are performed about 90% of all times. And
here’s the breakdown:
80%: Simple interrupted
10%: X suture
10%: all the rest
In our training, I focus on the commonly used techniques so you can tackle most,
if not all, clinical situations.
Why waste brainpower on things that are theoretical and you don’t need to use?
Let’s focus on what will get us to a great clinical outcome).
This is what you know so far:
• “Impossible” is nothing
• Suturing begins before you make incisions (visualization)
• Follow the instructions, my friend
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• Document, compare ,and learn your weak points and strengths (compare
immediate post-op to 1-week post-op)
• There is no need for talent or special skills to master suturing
Here’s something that changed my own mindset as an educator:
The sutures need to be loose and the knots need to be tight
Not the opposite!
Dr. Markus Hurtzler, master surgeon from Germany, said that at the USC
periodontal symposium Wow!
I kind of knew that for a long time from my clinical experience but when I heard
Markus say it, something clicked.
It’s the essence of suturing distilled into one sentence.
Many dentists create real tight sutures with loose knots that open prematurely.
Once the knots open, the wound is unstable and flaps are mobile, leading to
compromised healing.
This is important to know:
The tissues we suture in the oral cavity are fragile and require low forces for
approximation.
If you release flaps properly, contour bone anatomically when needed, and
create a passive flap, then
there is no need to over-tighten the sutures.
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The sutures will be kind of loose. The tissue will lay almost passively with little
tension, and the tight knots will stabilize all of that.
That’s all you need.
I will teach you this concept as part of the 9 LAWS OF SUTURING (coming later).
What’s the best way to learn suturing?
I have tried it all on myself and on the dentists I

mentored for the past 20 years—from pig
mandibles, fruit, plastics, egg yolk, and realistic
models—you name it.
As much as you try to simulate how it feels in

reality, it’s is always different. So I figured out that if you can’t simulate it, what is
the point to keep doing the same thing repeatedly and expect different results. It
needed to be something completely different.
I needed a system that would teach the principles of suturing techniques and
create clarity on the exact entry and exit points, the direction of the needle and
thread.
I needed a system that teaches the mechanics: how tissues get approximate and
how they get pulled and pushed to achieve the specific goal of the surgery. This is
why I create a physical model that enabled all of that. I called it the zPAD.
I incorporated common clinical situations that require suturing in this physical

device. Then came simple suturing exercises accompanied with video tutorials
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any dentist could understand and practice based in my instructions (remember,

“Follow the instructions, my friend”).
In this method, you can learn how to suture in

a pure schematic environment. Each exercise
is meant to train your hand–eye coordination
and create muscle memory for suturing. Each
exercise is meant to leave an imprint in your
memory, so when you get to suturing during a
surgery, you will use those principles in real
life and feel like you’ve done it many times
before.
Yes. It works just like that.
The teaching on the zPAD is based on the three principles for suturing success:
Safety: The basic principles that keep you, your assistant, and the patient safe. If
you think that has nothing to do with mastering suturing, think again.
Material: You don’t need to understand complex concepts that relate to tensile
strength, chemistry, and the exact composition of each suture. It’s confusing and
not so clinically relevant. What you need to know is which material and needle to
choose for which situation.
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Mechanics: How many twists and in which

direction, how to wrap, lock, release, twist
and tie so your sutures a loose and knots are
tight. It’s real simple if you have clarity and a
roadmap to achieving it.
All these principles are incorporated and

explained in in the NINE LAWS OF SUTURING
and the video tutorials that come with it.
SUTURE ANATOMY
The basic anatomy hasn’t changed in decades. You have a thread connected to a
needle in an area called the swaged part. The swaged part is the one we typically
hold when we handle suturing (part of your safety rules is to make sure you don’t
get poked).
To simplify things and create clarity in your mind, you need to know that each
component can be different based on various factors:
The thread factors: Material (gut, silk, Gortex, Prolene) and thickness (3-0, 4-0, 5-
0, 6-0—the more 0’s, the thinner the thread). Naturally, the thicker the stronger,
but certain materials are inherently stronger than others are (don’t worry, we’ll
explore that point). That’s all that’s important.
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The needle factors: Length, cross section (we only used cross cutting), curvature
(radius), and circle fraction (1/2, 3/4, 7/8). The choice of a needle has to do with
the tissues you are suturing and the location in the mouth.
Don’t focus so much on the specifications of each thread and needle. You can
literally go crazy looking at catalogs and the different options you have. The
“power of choice” will play against you, and you’ll get even more confused. I’ll
show you the exact sutures I use and save you time.
However, if you like to get into the details, understand everything, and research
each material before you make a decision, then you’ll find yourself over-
analyzing.
This will distract you from what’s important, and you will not make progress
because . . .
. . . over-analysis leads to paralysis
I need to teach you how to master suturing and get excellent in surgery, not get a
PhD in SUTUROLOGY!
So let’s focus on what’s important, and here’s where you start:
KNOW YOUR PACKAGE
Everything on the package describes what’s inside.
For example: C6. Huh?
That “C6” doesn’t mean anything to you and me. “C6” is a code word a company
assigned to a specific suture (like R2D2. Why? Because that’s his name).
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This code by a certain company includes the following: A needle that is X mm

long, of particular X curvature, with X mm long thread, X cross section, X material,
number of 0’s, etc.
All is on the package, and you need to study it.
Needle code
Curvature Material
Diameter
Cross section
Thread length
What is the best suture?
There is no such thing as the best suture. You can achieve the same results with
completely different types of sutures. Don’t fall into the old DOGMA (“you must
you use that, and you mustn’t use that”). It all depends on what you are trying to
achieve, and I will give you advice as well as tips to be able to decide. Often there
are several options, and you will train your eye and mind to see what I’m seeing.
Here is my first tip:
Suture Tip #1:
Narrow down to five kinds of sutures
All you need is five different suture types. Don’t exceed that, or you and your staff
will be confused and have lots of sutures go to waste (a box of 12 sutures can cost
up to $180!).
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I use the exact same suture 80% of the time and, in the remaining 20%, I use the
other four.
The brand doesn’t make a difference, but don’t stock up on cheap sutures. They
expire, and when they do, they lose their physical properties.
I did the research for you already.
I can save you some time experimenting by following what works. Keep it simple
as this table is your starting point.
GUT
If I told you that in my practice, a busy surgical practice, about 80% to 90% of all
sutures material is gut. What would that tell you?
It means you can achieve great results with gut. Does that mean you need to do
the same? Not at all. But let’s get rid of previous “brainwashing” against gut.
It’s the one of the best suture materials you can use. I use it as much as possible
and as much as applicable (you’ll see a law dedicated to that in the 9 LAWS OF
SUTURING).
Gut is an absorbable suture material

that takes about 3-5 days to start
breaking down. It resorbs by the
enzymatic activity of the body.
Resorbed inside the tissue, the knots
will easily pull off (or “fall off” during the healing period per your patients).
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The breakdown varies among patients and depends on their diet (increased
acidity with citrus drinks will expedite resorption). However, gut sutures keep
their tensile strength for about seven days and have excellent knot stability. They
hydrate in the mouth and practically “swell,” thereby tightening knots
(remember, the sutures should be loose but the knots tight).
Don’t use gut when you are expecting extensive swelling and tissue pull or with
a coronally advanced flap. It’s inappropriate to use gut suture in these situations.
However, often in soft tissue grafting, we need to suture grafts that we will not
have access to later. Gut is excellent for that.
I know you and many other doctors have

had a possible bias against gut as a suture
material. You may not like the “memory” of
the suture when it comes out of the package
(mostly true for chromic gut). Some dentists
don’t have faith that gut sutures will hold up
and that the flaps will open. That is only true for large augmentations and
coronally positioned flaps. For most procedures, it performs very well and actually
forces you to suture properly on all levels. Once you learn to overcome the
characteristics of gut sutures you don’t like, you start benefitting.
I’m sharing this with you with only one goal—to help you understand and master
suturing—and there are different way to do that.
So it’s totally fine if you’re not ready for gut yet. All will happen at the right time.
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Q: I don’t like the “memory” of gut. Can I put it in water to get rid of
the memory?
A: Yes. It’ll get rid of the memory, but the thread becomes more
stretchable and loses its properties. It may affect knot stability.
Remember, you need to get out of your comfort zone to master suturing. Getting
frustrated with gut if you’re not used to it is part of that.
Turn your frustration into
an advantage.
I believe this is one of the keys to success.
Q: When to use chromic gut??
A: It doesn’t make a difference. It’ll last a bit longer than plain gut
because of the chromic salts. Sometimes I see more inflammation
around chromic gut.
Q: What to do I do when they get stuck or locked prematurely?
A: They absorb blood that clots on the suture, and that can interfere.
The threads will not slide well one on top of the other, which causes
this problem. Solution: Wipe them with moist gauze. That’s especially
critical in continuous interlocking.
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Here are the exact two gut sutures that I use:
Q: Is there much difference in resorption rate depending on the

diameter of the suture, whether it's 3-0, 4-0, or 5-0?
A: No, it’s the same. The enzymatic activity that is resorbing the
suture is the same, regardless of the thickness.
Common use in periodontal surgery and suturing a graft that will be covered by a
flap.
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PROLENE
When it comes to withstanding forces, Prolene sutures work
well. They combine being gentle and kind
to tissues, but also are strong enough to
keep flaps stable under pressure.
I love using Prolene polymer sutures for soft tissue grafting when I need to
coronally advance flaps and keep them in for a few weeks (there is virtually no
inflammation around them).
One major disadvantage is knot stability. You

need to know how to handle Prolene to create a
stable knot. They technically slip on one another,
and you need to change the knot twisting
routine. You need to twist more times and in a
certain way (see SUTURE LAW 9).
One other problem with Prolene is that they “poke.” The short ends are very rigid,
and often patients will tell you that what bothered them the most is a huge
aphthous ulcer from the suture.
How to solve that?
KEEP ‘EM LONG
Keep the ends long (~15mm) and they will be flexible, and problem
solved. They will act like a flag, and patients may occasionally bite on them,
but the poking problem is resolved.
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Here are the exact Prolene sutures that I use:
When not to use Prolene?
Don’t use them suturing mucosa to mucosa. An example is a vertical release that
extends into the mucosa. They get embedded and hard to remove. For these
situations, I like to use gut 5-0.
Q: Can you stabilize sutures to composite to create

an anchor for a pedicle or a coronally advanced
flap?
A: YES. However, it’s not practical. It’s a terrible

plaque trap and compromises the esthetic. At the
follow-up, you’ll find the patient’s meals under the sutures. Learn the
continuous sling-in suturing made simple training to solve these problems.
31 | P a g e
GORTEX
Gortex is the brand name for a synthetic ePTFE
suture that is excellent for procedures that
cause significant swelling like augmentations. It
is easy to handle and has quite good knot
stability.
The reason I like to use it in ridge augmentation

is its high tensile strength. The sutures are almost always there, holding the soft
tissues at the 1-week post-operative.
Gortex has its own nomenclature that is different from other sutures. For
example: Gortex 5-0 is equal to a 4-0.
To save you time and confusion, here’s the conversion:
Here is the exact Gortex suture that I use:
32 | P a g e
The companies “want” to confuse you. Remember, the needle nomenclature is

just an arbitrary code.
Here is the comparison between the different needles:
Using Gortex is recommended for large flaps and augmentations, where swelling
is expected to occur.
33 | P a g e
Where to start?
“Ziv, show me your suturing techniques so I can copy you.”
I get this all the time, and copying is great. Actually, I want you to “steal”
everything you see working for me and others (like the saying, “Good artists copy,
great artists steal”).
Here’s the catch:
If I just show you the techniques when we train together, you will never be able
to master suturing.
Why not?
Because suturing is not only about technique. Being a suturing robot doesn’t
work. You will get frustrated.
Each clinical situation is different, and you need to understand general suturing
principles first.
It’s like if I would be your driving instructor and teach you how to turn left, how to
turn right, and how to make U-turns but . . . I didn’t tell you about the
recommended speed. Can you imagine making a U-turn at 65 MPH?
You need to know some rules that will put all the techniques in perspective to
keep you safe and make you successful.
The rules and laws of suturing will teach how to be mindful of the tissues you are
suturing, how to choose the right materials, and how to apply the right
mechanics.
34 | P a g e
THE 9 LAWS OF SUTURING
The nine laws of suturing give you the frameworks and principles of suturing. My
goal in creating them was to remind you constantly to focus on safety, materials,
and mechanics.
These laws are meant to act as silent voices in your head when you are suturing
or even if you just think about suturing.
Remember, thinking about suturing starts before you make even one incision. I
taught that you need to take suturing in consideration when you create a flap
design.
Now, I’m adding another layer (actually nine layers in the 9 Laws).
So let’s get started.
LAW 1 -
You shall always suture SLOWLY
Slow down everything. Don’t rush.
I often observe dentists trying to suture at light speed. Their fingers, hands,
needle, and thread look like a big tornado, and the results are mediocre at best.
These “fast-suturing” doctors fail because they eventually harm themselves,

assistants, and patients. They also harm the tissues and outcomes by not being
35 | P a g e
meticulous with the entry and exit points and technique, thus the creating wrong
mechanics.
When you drive your car at 100 MPH all the time, you are guaranteed to crash.
Slow it down.
This is how I look at speed:
Suturing is like giving an injection or making an incision.
You don't do those fast, do you?
The fast cutting and chopping is for butchers. We are not

them.
If you want to be accurate and precise with your suturing, S L O W D O W N.
“But Ziv, I can do it fast and get good results. What’s the problem?”
Awesome! Good for you!
There is a juggling school in town that will take you, and maybe you’ll even be
able to get into a circus as a performer.
I don’t believe in surgical acrobatics, speed, or trying to impress with speed.
If you rush, you will make mistakes.
When you rush, you will poke yourself, your assistant, or your patient; you’ll get
more entanglement, wrong tissue engagements, and wrong mechanics.
Use these weapons of mass destruction carefully: Cotton pliers, scissors, needles.
“There is more to life than speed.” (Mahatma Gandhi)
36 | P a g e
LAW 2 -
You shall always RESPECT your flaps
Consider the tissues you are suturing as sacred. Do no harm to the soft tissues so
they stay intact and respond well to your suturing.
Remember, “You can’t suture hamburger meat”
A big problem you may have seen are tears in the flap.
You pass the needle through one flap, then the other, tie a knot only to see how
the suture cuts through the flap. OOOPS.
You just created a tear or a “cut-out,” which is a suturing complication. The suture
didn’t work out, and you can’t suture the same spot again.
37 | P a g e
First, why do cut-outs happen?
There are three main reasons:
1. Friable tissue: Red and swelling gingival margins usually indicate friable
tissue. Pre-diagnose this. As you apply normal forces with the suture, the
tissue cuts out.
2. Too much force: Any tissue will tear with significant force. Remember, we
only want the knots to be tight. The sutures need to be loose.
3. Too close to the edge: When you see friable tissue, don’t engage it. Create
an entry point that is more apical and in good tissue. Take a bigger “bite”
when engaging the flap to bypass tissue that has poor quality. Don’t apply
extensive force. The oral soft tissues are thin and delicate. Only light forces
are needed for successful suturing.
As a general rule:
Don’t get too close to the edge.
The entry is 2 to 3 mm from the flap edge.
38 | P a g e
Q: How about the papilla?

Does the 2-3 mm from the
edge still apply?
A: Yes. The rule still

applies. You need the
check the direction of the
force that will be applied
by the suture. You can be
less than 2-3 mm from the
side of the papilla but 2-3 mm from the tip, because that is the
direction of the force.
THE TWIST WRIST
Needles are curved, and therefore your entry into the tissue needs to be in a
curved motion. If you enter in a straight line, you are using a “stabbing” motion.
A curved cutting instrument (needle) going in a straight line creates damage.
How do you generate a curved motion?
It all comes from the wrist. The wrist with the needle holder can be twisted to
generate this motion with the needle. The needle needs to be perpendicular to
the needle holder. Now, go and watch the wrist-twist video in the online course.
39 | P a g e
Q: What is the ideal number of sutures?
A: The ideal number of sutures is the least number of sutures to

achieve
Hemostasis, approximation, and stability.
I used to be very generous in suturing, meaning I used to place too many sutures.
Each entry and exist point in the flap is trauma that creates inflammation and
compromises the blood supply.
Therefore, each additional suture that is not really needed compromises your
surgical outcome. With more sutures, there is a higher risk for cut-outs.
Here is advice on minimizing the number of sutures:
Stop at the point where you think you are half-way through your suturing process.
(It’s arbitrary at this point, but I’m trying to help you. Give this a try).
In most cases, you’ll notice that you are actually more than half done. That will
teach you to be conscious about the number of sutures placed and encourage you
to minimize them.
Less is more
40 | P a g e
You shall always CONTROL your needle and thread
LAW 3
This is another safety law.
Always be in control of the needle and thread.

Control of the suture material prevents injuries and
minimizes entanglements and pre-mature locking of
the knots.
From the moment you take the suture out of the

package until you discard of it at the end, you need
to be in control of it. That means holding it in a safe way, keeping it away from
unwanted areas and surfaces, and discarding it in a safe way.
Know where your needle and threads are at all times.
41 | P a g e
You need to hold it at the swaged part to avoid

“poking” yourself.
Remove the needle from the package with an

instrument and place it in a position perpendicular
to the needle holder. That’s a starting point for 80%
of cases. Occasionally, we will need a different
angle when suturing in the distal regions.
What to do with all this excess thread material?
When the suture is new out of the package, you have a lot suture material (a very
long thread) that is tricky to manage and sometimes blocks the surgical field or
creates entanglements.
Here are two tricks to prevent that:
The “Pinky Hold”: Lock the thread

material between Finger 5 (pinky) and
the palm. That will hold it away from
the surgical site and allow you to
control it at all times. Now, watch the
tutorial video on the Pinky Hold.
42 | P a g e
The “Wrap Around”: This helps when

you are ready to tie a knot and have a
lot of thread material. Hold the needle
at the swaged part between Finger 1
and Finger 2. Now, wrap the excess
suture material around Fingers 3, 4, and
5. Now you have less free thread material, and the suturing is simplified. Go
ahead and watch the video tutorial in your online course.
Finish strong and safe
When you are finished with your procedure,

place the sharp part of the needle inside the
needle holder and place it on the tray.
Your assistant will thank you for that. Don’t

forget to share these laws with your supporting
staff.
We can all benefit from a refresher on safety precautions. The first the laws are
dedicated for that. Know them well (1. Suture slowly, 2. Respect your flaps,
3. Control your needle and thread).
We have six more to go. Hang in there!
43 | P a g e
LAW 4 -
Go with your GUT
In my opinion, the more gut sutures you use, the
better you’ll do.
Using gut teaches you the appropriate force but is

still relatively forgiving, even if you didn’t use a
perfect technique. It resorbs at the right time from within the tissue and has good
knot stability.
Patients prefer that as well, because the perceive gut sutures as advantageous,
and their perception of us is important (I wouldn’t recommend gut if I didn’t think
it was advantageous myself, so this is a double win).
You can use gut in areas you can’t visit again, such as underneath a flap or a
bridge. Don’t feel pressure to use gut if you’re not ready. You can certainly
achieve great outcomes with different materials.
I know you may be concerned with the “memory” of the suture and it getting
stuck when blood clots on it. I’m with you on that, and there are good solutions
for that.
When you’re ready to tackle gut, I’m here for you to tackle these problems and
start benefiting from all that gut sutures offer us.
44 | P a g e
LAW 5
Go MICRO with delicate tissues
The idea behind this law is to adjust the size of the thread and the needle to the
structure you are suturing.
If you are suturing a large maxillary flap, the sheer

size and density of it can tolerate large needles and
require a relatively thick thread (4/0) to position it.
On the contrary, when suturing in the esthetic
zone, aligning papillae, friable tissues, or lower
incisors flaps, you need to “go smaller” (or “go
MICRO”).
When you use 5-0 or 6-0, you will have less tissue trauma and cut-outs.
Here’s a technique I call the “Prayer Technique.” It allows me to create primary

closure with my suturing using 5-0 gut sutures. Pay attention to the diagonal
incisions that help me create mini-flaps that will cover the extraction sockets after
the teeth have been extracted and the sockets grafted. It takes 10 to 15 minutes
of your time to suture properly, but the outcome and satisfaction is certainly
worth it.
45 | P a g e
Extraction of all lower incisors leaves an abundance of tissue behind that, if not managed, will delay
healing and create a sub-optimal ridge for implants.
The key here is to create a diagonal incision through the papillae, mobilize them, and rotate them on
top of the extraction sockets (following bone grafting).
Once rotated, on top of the sockets, create multiple X sutures with simple interrupted, using Gut 5-0
for primary closure and expedited healing.
It’s the strength & slippage KNOT the material
LAW 6
The material doesn’t make a difference. Again: The material doesn’t make a
difference.
This may come as a surprise to you and is a major dogma you probably heard:
“You must use this material, and you mustn’t use that one.”
46 | P a g e
The actual chemical composition of the suture doesn’t make a difference and, in
most cases, you can use anything to achieve a good surgical outcome.
Silk is not the devil, and it’s totally fine to use it. It’s not the actual material that
counts, but how strong it is and how it ties (suture strength and knot slippage).
What is tensile strength really (in a super simple way)?
Without confounding you with physics, tensile

strength is resistance of a material to breaking
under tension. It’s like taking a rubber band and
stretching it. You can stretch and stretch and, at
some point, it’ll tear. The longer a material lasts
before it tears, the more tensile strength it has.
Now, imagine the forces you applied to stretch a rubber band until it breaks are
the same forces applied on two sutured flaps. These forces happen when the
tissues swell and the two flaps can start separating.
If you had control over the suture, holding both flaps, would you choose one with
high tensile strength or low tensile strength?
Naturally, you want a suture with high tensile strength to withstand the forces
caused by swelling. I simply call them strong sutures, like Gortex and Prolene (the
strength of the material matters here).
47 | P a g e
Knot slippage
Certain suture threads easily slip on one another.

An example is Prolene sutures.
What does it mean?
If the threads easily slip and slide on one another,

you will have less pre-mature tightening and
entanglements. On the flip side, you will have less stable knots, because they tend
to slide on one another (there is no traction between them, so to speak).
With the Prolene material, you benefit from good tensile strength, but will have
to tackle high knot slippage with a special way to suture (see Law 9).
So when choosing a suture material, consider the strength (or tensile strength)
and knot slippage, not the material per se. Choose a material that handles well in
your hands and that is convenient for tying knots. When you expect swelling, and
stretch of the tissue, go with a suture that is strong enough to withstand it.
LAW 7 -
TEST your suture
This law is applied just before typing a knot.
You completed the entry and exit points

based on the suturing you are trying to
achieve. You envisioned how you want the
48 | P a g e
wound to close and the flaps to move. This is when you can test your suture.
Testing the suture involves applying forces on both ends of the suture as if you
are tying a knot but without actually doing it. Observe the mobilization of your
flaps and see how the surgical wound closes. You are basically testing if the
mechanics you envisioned are happening.
If you don’t like what you see, take it all out and re-do the suture.
If all looks good, tie a knot.
Law 7 is all about making sure the mechanics of the suture are working well
before you tie the knot. At some point, you will not have to test all of your sutures
(especially the simple ones), but keep in mind that it’s always good to check.
LAW 8 -
DON’T PULL AWAY

This law addresses the problem of “Air
knots.”
“Air knots” happen when a knot gets

locked prematurely away from the tissue.
As such, it’s completely useless and
needs to be removed.
49 | P a g e
“Air knot” = “Premature locking”: How to prevent that?
What we need to do is control the entanglement so it happens close to the tissue.

One of the keys of making it happen is by not pulling away from the tissue.
If you pull away from the tissue, your knot will lock prematurely, and you’ll get an
“air knot.” Make both long and short ends almost equal, using the Wrap Around
Technique from Law 3 and tighten parallel and close to the tissue.
You can also tighten the short end in a “back-and-forth” motion after you made
you first two throws, which creates some knot stability. When your first two
throws are reasonably stable, STOP BREATHING, NOBODY MOVES A MUSCLE,
and complete the throws in the opposite direction.
If you don’t pull away and stay parallel and close to the tissue, you will get a
perfectly stable knot. We will learn how these throws work in the next suturing
law.
LAW 9
#0s = #THROWs
Last but not least!
So many dentists wonder, How many throws? In which direction to start?

Clockwise? Counter clockwise?
Here is a general rule that will help you:
50 | P a g e
The number of the 0s (how many? 3-0, 4-0, 6-0?) is the number of the throws
Example: 4-0 suture
2 in one direction
1 in the opposite direction
1 in the original direction
2 + 1 + 1 = 4  4-0 suture
Example: 5-0 suture
2 in one direction
1 in the original direction
2 + 1 + 1 + 1 = 5  5-0 suture
Q: Where to start clockwise? Or counterclockwise?
A: It doesn’t matter mechanically and it’s more about convenience. I

personally don’t look at it as clockwise or counterclockwise. I look at it
as “away from me” and “towards me.”
51 | P a g e
Let’s repeat one of the previous examples (with a different terminology):
Example: 4-0 suture
2 away from me
1 towards me
1 away from me
2 + 1 + 1 = 4  4-0 suture
Q: What if I want to do extra throws?
A: Enjoy! It doesn’t hurt, but you are wasting suture material, and
your knots will be bigger.
Q: I noticed that this rule is not ideal for Prolene.
A: That is correct. For Prolene, I add 1 and the sequence is different.

Law 9 becomes #0s + 1 = #THROWs (see example below).
Example: Prolene 5-0 suture
3 away from me
2 towards me
1 away from me
3 + 2 + 1 = 6  4-0 suture
52 | P a g e
PUTTING ALL 9 LAWS TOGETHER
Many dentists have challenges suturing large flaps. The most predictable strategy
is to first align the flap starting from the mesial. Then create an interrupted
horizontal mattress with Gortex 5-0 and overlay with continuous interlocking gut
4-0.
53 | P a g e
Here is the summary of the 9 LAWS OF SUTURING. Recite them before you
practice suturing with your zPAD.
THE 9 LAWS OF SUTURING
1. You shall always suture SLOWLY
2. You shall always RESPECT your flaps
3. You shall always CONTROL your needle & thread
4. Go with your GUT
5. Go MICRO with delicate tissues
6. It’s the strength & slippage KNOT the material
7. TEST your suture
8. DON’T PULL away
9. #0s = #THROWs
Don’t be a technician dentist.
The techniques are important, and you can practice them after watching the
video tutorials. The 9 LAWS OF SUTURING are your 9 layers of confidence that
help you with safety, choice of materials, and the mechanics of suturing.
54 | P a g e
Now that you have framework and a roadmap to mastering suturing, it’s time to
get to work! Watch the videos tutorials, review the suturing techniques manual,
and practice on your zPAD.
Many dentists before you started exactly where you are at today. The road to
mastering suturing is already paved for you, and I closely mentor dentists who go
through this roadmap.
You will master suturing.
Ziv.
P.S.
If you followed the framework of this book, you now

have the mindset to suture with clarity and confidence.
Your next step in the roadmap is to practice the actual
techniques and correlate them to different types of
surgical procedures.
Watch the video tutorials, study the suturing technique

step-by-step manual, draw, illustrate, and practice on
your zPAD.
Mastering suturing is within your reach, and I am here to

coach and mentor you throughout this process.
55 | P a g e

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What are the 9 Laws of Suturing?

What are the 9 Laws of Suturing?

What are the steps to suturing large flaps?

What are the steps to suturing large flaps?

Back to the SUTURE: Your Roadmap to Understanding & Mastering Suturing

It’s not that things are impossible.

It’s your mind telling you, “It’s Impossible.”

So let’s go back to word, “Impossible.”

So here are the first tips of this book

and the keys to your success:

Now let’s take it a step further.

Would you be able to learn a critical surgical skill in 7 days?

Would you do it in 7 hours?

I’m not just talking about any skill.

SUTURING: Your ability, with

Mastering suturing may feel “impossible” for you today.

Countless dentists already mastered the suturing game.This is your irrefutable

Here’s my second and third advice in this book:

• You don’t have much experience,

This is what it will take from you:

Simply follow the instructions, my friend.

What do I mean by that?

I’ve taught thousands of dentists over the years,

I tell them the same, “Follow the instructions, my

You must follow the instructions step-by-step. No deviations.

Do as I do initially to create effective and predictable knots and surgical wound

WHAT’S HOLDING YOU BACK?

First, you need to be stripped from the common

This is the first step in turning you into a suturing

Here’s my plan for you to grow your suturing skills:

Can we shake hands on that?

Suturing is not what you were indoctrinated to believe it is.

It’s not a secret skill reserved to specialists or to uber-talented dentists.

It doesn’t take decades of practice or using instruments and materials available to

The Three Pillars of Suturing

Here’s SECRET #1:

Of all the suturing techniques I use, 95%

Yes. Just one entry and one exit point and

The “secret sauce” is understanding and implementing safety principles, choosing

If you’re like most dentists, suturing is a struggle.

Tears, entanglement, knots opening, flap cut-outs, sutures that

unpleasant suture problems and complications.

Well, confidence can be acquired. Clarity can be created.

Here’s what NOT to do:

• Don’t give up or be discouraged by anyone.

I know you can master this suturing

No matter if you are just starting out or if you

It feels like there is nowhere to turn to if you desire to learn suturing.

There could be only three explanations:

Howard Farran, founder of DentalTown, told me the following during an

There was no time to waste.

In this system, I want every dentist to

• go back to sound surgical principles,

Therefore, I called this book BACK TO THE

“I finally GET suturing!”

If this works on a person with no dental knowledge

Everyone operates at 100% capacity of their current mindset ceiling.

So how would you increase your potential if you’re already at 100%?

This way, you can reach higher and higher